Project Summary: The purpose of this proposal is to foster the clinical research skills and scientific development of Jamieson Bourque, M.D., M.H.S., to facilitate his transition to an independent clinical investigator. Dr. Bourque's training goal i to receive sufficient clinical research training to successfully pursue investigator-initiated R01 funding. The University of Virginia is an ideal venue to perform innovative research involving the noninvasive assessment of microvascular dysfunction and the application of exercise therapy to this disease process due to the strong research and clinical expertise of faculty in both CMR and exercise therapy and the strong institutional commitment to Dr. Bourque. His primary mentor, Christopher Kramer, M.D., is an internationally- respected thought leader in the application of cardiac magnetic resonance imaging to assess microvascular function. He has a long proven mentorship track record. Importantly, Dr. Bourque's career development plan includes advanced classes in vascular biology, advanced exercise physiology, image acquisition and processing, biostatistics, and research ethics that will strengthen his ability to pursue his long-term goal of developing a specialization in the noninvasive assessment of microvascular dysfunction and the application of exercise therapy and patient-centered outcomes clinical research to this morbid disease process. Dr. Bourque's research question is of paramount public health importance. Angina is a highly morbid condition but obstructive coronary artery disease (CAD) is seen in <50% of cases. These patients may have microvascular dysfunction, which can be assessed noninvasively by cardiac magnetic resonance imaging (CMR). The optimal treatment of this morbid population has not been sufficiently studied. Multiple medications and therapeutic exercise may improve microvascular function, aerobic capacity, and outcomes including anginal symptoms, quality of life, and cardiac events in this highly prevalent patient population. The specific aims of Dr. Bourque's proposal are: 1) to determine the predictors of reduced myocardial perfusion reserve and patient- centered outcomes in patients with angina and no obstructive CAD; and 2) to compare changes in myocardial perfusion reserve, aerobic capacity, and patient centered outcomes between intensive medical therapy and intensive medical therapy plus exercise in patients with angina and no obstructive CAD. To address these aims, Dr. Bourque will perform a prospective study of patients with anginal symptoms and no obstructive disease on coronary angiography, who will undergo a clinical assessment followed by CMR perfusion imaging. Those with reduced perfusion reserve will be randomized to medical therapy versus medical therapy + exercise and changes in perfusion reserve, aerobic capacity, and patient-centered outcomes will be assessed. The invaluable training from this research project, robust mentorship, and didactic program will greatly assist Dr. Bourque in fulfilling his goal of becoming an independent clinical investigator.